Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based treatment model designed to assist children, adolescents, and their families in overcoming the negative effects of a traumatic experience.

This evidence-based method has been proven effective for treatment after multiple traumas or a single traumatic event, and therapists trained in TF-CBT are frequently able to help children experiencing the emotional effects of trauma address and resolve these effects. 

The Development of TF-CBT

The clinical work and research of Judith Cohen, Anthony Mannarino, and Esther Deblinger led to the development of TF-CBT. Out of a desire to better understand the difficulties faced by traumatized children and adolescents, they expanded traditional cognitive behavioral methods, extending their reach by incorporating family therapy and using a trauma-sensitive approach in the therapy’s application to children and youth. 

Preliminary research on this treatment model was followed by five randomized controlled trials, which demonstrated the effectiveness of the TF-CBT model on the target population. Many other researchers have gone on to replicate these results, proving the efficacy of this model in treating children and adolescents who have experienced traumatic stress. 

How TF-CBT Works

In TF-CBT, interventions specifically tailored to meet the needs of children and adolescents experiencing emotional and psychological difficulties as a result of a trauma are integrated with humanistic, cognitive behavioral, and familial strategies. This treatment is short-term and generally lasts no more than 16 sessions, as more than 80% of traumatized children see improvement in this time.

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Both parents and children may become able to better process emotions and thoughts relating to a traumatic experience through TF-CBT, which can provide those in therapy with the necessary tools to alleviate the overwhelming thoughts causing stress, anxiety, and depression. TF-CBT can help people who have experienced trauma learn how to manage difficult emotions in a healthier way.  A secure and stable environment is provided in order to enable children to disclose details of trauma. It is at this time the cognitive and learning theories of treatment are applied. Children are shown how perceptions may be distorted and are given the tools to redesign those perceptions.

TF-CBT is a skills-based model, and it requires the child and parent to practice its components in order to be optimally effective. Parents and children are commonly asked to practice skills at home. The goal of TF-CBT is to allow both child and parent to continue to develop their skills and communication techniques in a healthy manner. 

Core components of TF-CBT include: Practitioners of TF-CBT strive to give parents the resources and skills necessary to help their children cope with the psychological ramifications of the abuse or other trauma. 

  • Psychoeducation and parenting skills 
  • Relaxation 
  • Affective regulation
  • Cognitive processing of the trauma
  • Trauma narrative
  • In vivo mastery of trauma reminders
  • Conjoint child-parent sessions
  • Enhancing future safety and development

The success of TF-CBT relies heavily on a trusting, genuine therapeutic relationship between therapist, child, and parent. The therapist incorporates individual child and parent sessions as well as joint sessions using family therapy principles. Including the non-offending parent in therapy can help the parent cope, and this also allows the parent to support the child in this treatment framework. Practitioners of TF-CBT strive to give parents the resources and skills necessary to help their children cope with the psychological ramifications of the abuse or other trauma. 

Issues Treated with TF-CBT 

TF-CBT’s main application is the treatment of posttraumatic stress. The goal of this therapy is to help survivors of trauma, whether the trauma was a single occurrence or multiple events, address and resolve the distress resulting from these events and ultimately decrease the negative behavior patterns and emotional responses often developing as a result of sexual abuse, physical abuse, or other trauma. Children and adolescents who have experienced these traumas may find TF-CBT an effective method in the process of returning to a healthy state of functioning. 

Childhood traumas such as abuse, domestic violence or neglect can often lead to symptoms of PTSD, depression, and anxiety. Children or young people between the ages of 3 and 18 who have been sexually or physically abused or exposed to domestic violence may obtain benefit from TF-CBT, whether they have experienced repeated episodes of trauma or a single occurrence of trauma. The non-offending parent or caregiver will typically also participate in the therapy. Children who are learning to cope with the death of a loved one have also been shown to obtain great benefit from TF-CBT.

Children living with their parents, in foster care, kinship care, group homes, or residential programs may all be helped by TF-CBT. 

Who Provides TF-CBT? 

Experienced therapists with knowledge and training in child development, who can assess and treat a wide range of child mental health conditions, are typically the recommended providers of TF-CBT. Training is required for therapists to practice from a trauma-focused framework, and therapists who have received this training are also encouraged to seek out supervisors or consultants who have experience with the TF-CBT model. 

Therapists can access training in the TF-CBT treatment model through a certified introductory training course or web-based training program. To be certified, practitioners with a master's degree or higher must participate in a 2-day live training, participate in follow-up training or consultation twice a month for six months or once a month for 12 months, participating in nine out of 12 consultation or supervisory sessions provided by a treatment developer or graduate of the TF-CBT Train the Trainer Program. Further, a practitioner is also required to complete three different TF-CBT cases, where two or more of these cases include participation from caretakers. Practitioners must also pass a knowledge-based exam once they have met the above requirements. 

How Effective Is TF-CBT? 

Research shows children and adolescents experiencing severe emotional repercussions due to trauma frequently respond well to this technique. To date, 11 empirical studies conducted on the impact of TF-CBT on adolescent survivors of trauma have demonstrated its usefulness in reducing symptoms of depression, anxiety, and PTSD. Randomized clinical trials comparing TF-CBT to play therapy, child-centered therapy, and supportive therapy show TF-CBT to yield greater gains over fewer sessions. Studies done up to two years after the conclusion of TF-CBT demonstrated these gains to be sustained over time. 

Limitations of TF-CBT

​TF-CBT may not be appropriate for children and adolescents who have significant conduct or other behavioral concerns that were present before the trauma may not receive significant benefit from TF-CBT and may see greater improvement with approaches in which they are first helped to overcome these difficulties. 

Adolescents who abuse substances or who are suicidal may temporarily see a worsening of symptoms with TF-CBT's gradual exposure component. TF-CBT may still be helpful when treating children who are thus affected, but often the pace or order of interventions must first be modified. Dialectical behavior therapy or another stabilizing therapy approach is often used before TF-CBT is attempted with adolescents who have a history of running away and/or severe self-harm and other parasuicidal behaviors. TF-CBT may still be of benefit and is not necessarily contraindicated in these cases. 

References: 

  1. Cohen, J.A., Mannarino, A.P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: The Guilford Press.
  2. Cohen, J. A., Mannarino, A. P., & Iyengar, S. (2011). Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence. Archives of Pediatrics & Adolescent Medicine, 165 (1), 16-21.
  3. TF-CBT Certification Criteria. (n.d.). Retrieved from https://tfcbt.org/tf-cbt-certification-criteria
  4. ​Trauma-focused cognitive behavioral therapy for children affected by sexual abuse or trauma. (2012). Child Welfare Information Gateway, 6. Retrieved from https://www.childwelfare.gov/pubPDFs/trauma.pdf
  5. Weiner, D. A., Schneider, A., & Lyons, J. S. (2009). Evidence-based treatments for trauma among culturally diverse foster care youth: Treatment retention and outcomes. Children and Youth Services Review, 31(11), 1199 1205. 
  6. What is TF-CBT? (n.d.). Retrieved from http://academicdepartments.musc.edu/projectbest/tfcbt/tfcbt.htm